Matthew DeCamp, MD, PhD; Lisa Soleymani Lehmann, MD, PhD; Pooja Jaeel, MD; Carrie Horwitch, MD, MPH; for the ACP Ethics, Professionalism and Human Rights Committee *
Disclaimer: The views expressed in this manuscript do not necessarily reflect the views of the National Center for Ethics in Health Care, the Department of Veterans Affairs, or Harvard University.
Acknowledgment: The authors and the EPHRC thank peer reviewers Michele Barry, MD, John A. Crump, MBChB, MD, Marion Danis, MD, Ana S. Iltis, PhD, Tracy L. Rabin, MD, MS, and the many leadership and journal reviewers of the paper for helpful comments on drafts; Sean Lena for research assistance; and Lois Snyder Sulmasy, JD, and Kathy Wynkoop of the ACP Center for Ethics and Professionalism.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3361.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, American College of Physicians, Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. DeCamp: Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205.
Dr. Lehmann: National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Avenue, NW, Washington, DC 20420.
Dr. Jaeel: Internal Medicine Residency Training Program, University of California–San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093.
Dr. Horwitch: Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA 98101.
Author Contributions: Conception and design: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Analysis and interpretation of the data: M. DeCamp, L.S. Lehmann, P. Jaeel.
Drafting of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Critical revision of the article for important intellectual content: M. DeCamp, L.S. Lehmann, C. Horwitch.
Final approval of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Collection and assembly of data: M. DeCamp, L.S. Lehmann.
This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.
Table. Case Scenarios
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Chester B Good, N Randall Kolb, Lindsay Nakaishi, Mark Meyer
UPMC Helath Plan, UPMC Family Medicine Global Health Track
April 19, 2018
Ethical Obiligations are Important, but should not Dissuade Physicians from Participation in Short-term Global Health Experiences
The Position Paper of the American College of Physicians (and associated editorial) on ethical obligations regarding short-term experiences in global health (STEGH) is timely and appropriate (1,2). However, as physicians deeply involved in a clinic in Honduras (Shoulder to Shoulder Pittsburgh/San Jose,www.shouldertoshoulderpgh.org) which serves as a STEGH site for medical trainees and practicing physicians, we are concerned these guidelines might overly discourage participating in STEGH. All five of the core positions from the ACP are explicated and embedded in a well-established, evidence-based medical-community development strategy known as Community Oriented Primary Care (COPC) (3). The COPC model revolves around the community’s resources and needs. As each community is unique, this framework requires engagement with the community before developing programs, and informs proper development over time. The COPC model facilitates defining the community’s health priorities. It sustainably and ethically addresses disparities.Our partnership began 18 years ago with a small Honduran community whose health priorities were gleaned after more than 30 hours of direct discussion with community leaders during our initial two-week brigade. We have returned to the same community with medical teams at least twice a year since, applied the COPC model and built a water purification system, feeding program for undernourished children, and a locally run healthcare clinic with 8000 patient visits annually. Currently, University of Pittsburgh medical trainee STEGH participants use COPC to collaborate with local partners to address preventative well child care, chronic disease management, and mental health. We have sought to be thoughtful and deliberative in our program development and to be consistent with the ethical obligations of STEGH. However, it took many years to get to where we are today, and it has been a learning process. The position paper should serve as a guide for STEGH programs to follow, but should not discourage those seeking to enter a relationship with global health partners.Finally, we would posit that the position paper ignores one important aspect of the ethics of STEGH- that is, where STEGH is combined with faith based medical service. We understand the attractiveness of the arrangement (particularly since much of our funding comes from local churches). However, we believe that combining these efforts together raises another tier of potential conflicts of interest. As such, we have carefully avoided combining medical brigades with religious brigades in our Honduran partner village to reduce the risk of any perception of quid pro quo care relationships.1. DeCamp M, Lehmann LS, Jaeel P, Hortwitch; ACP Ethics, Professionalism and Human Rights Committee. Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper. Ann Intern Med. 2018. [Epub ahead of print]. doi:10.7326/M17-3361 2. Farquhar C, Nduati RW, Wasserheit JN: Ethical obligations in short-term global health clinical experiences: the devil is in the details. Ann Intern Med. 2018 [Epub ahead of print]. doi:10.7326/M18-0566 3. Gofin J, Gofin R, and Stimpson JP. Community-oriented primary care (COPC) and the Affordable Care Act: An opportunity to meet the demands of an evolving health care system. J Prim Care & Comm Health. 2015;6:128-133.
Dr. Mitch Brinks, Dr. Justin Denny, Dr. Sara Schwanke Khilji
The Oregon Health & Science University, Global Southeast Asia, Oregon Health & Science University, Portland, Oregon, USA
April 27, 2018
Ethical Standards Supporting Quality STEGH: A Case Study in Myanmar
We applaud the recent publication by Dr. Decamp and colleagues, “Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (STEGHs): An American College of Physicians Position Paper” . While Western ethical frameworks may not be generalizable globally , DeCamp et al. address an important gap regarding ethical considerations in clinical international health experiences for physicians . In their editorial, Farquhar et al. ask how physicians can determine which organizations meet ethical standards. Until objective measures are developed, we must rely on organizations to share information from their experience with STEGHs. As such, we offer a brief summary of the authors’ experience developing a collaboration between Mandalay Eye Hospital (Myanmar), Tipitaka Eye Hospital (Myanmar), and the Casey Eye Institute (CEI) (U.S.A.), to evaluate alignment with ACP positions for STEGHs. Position 1. The partnership’s mission statement, “Reducing preventable blindness in Southeast Asia through education, research, and delivery of care” and linked goals and objectives clarify for participating physicians their ethical obligation to, first and foremost, improve the well-being of the host community. STEGHs meet host, partner, and oversight body ethical standards; monitoring care outcomes is required.Position 2. The partnership develops strategies in concert with informed and representative local health leaders, with the fundamental goal of achieving leaders’ long-term vision. Comprehensive, coordinated discussions and regularly scheduled process evaluations are integral to each program. Consultation with oversight organizations, relevant NGOs, and scientific guidelines ensures equitable, sustainable, and effective programs.Position 3. Myanmar leaders supervise program monitoring and advise best cultural practices. Regular bidirectional visits enhance understanding and essential in-person communication. Consistent site visits strengthen program identity and help local partners invest themselves, providing balanced leadership. Position 4. Preparations include individual, group, and cultural liaison discussions of potential logistical and ethical challenges. During STEGHs, support is readily available from both the hosting and sending site. Post-visit debriefs evaluate and address distressing challenges and improve preparation for future teams. References: DeCamp M, Soleymani Lehmann L, Jaeel P, Horwitch C. Ethical obligations regarding short-term global health clinical experiences: An American College of Physicians position paper. Ann Int Med 2018 Mar 27 [epub ahead of print].2 Stonington S, Ratanakul P. Is there a global bioethics? End-of-life in Thailand and the case for local difference. PLoS Med 3(10):e439.3 Farquhar C, Nduati RW, Wasserheit JN. Ethical obligations in short-term global health clinical experiences: The devil is in the details. Ann Int Med 2018 Mar 27 [epub ahead of print].
Riley G. Jones MD MSc MSc
Global Health Fellow, University of Florida
May 24, 2018
Ethics in global health- the definitions matter
I read the ACP position paper on ethics in short-term global health clinical experiences by DeChamp and colleagues (1) with much enthusiasm. While the authors do a decent service in putting forth a set of guidelines, I was disappointed to see their assertion that “global health… emphasizes vulnerable populations in underserved settings” and then goes on to cite Koplan et al. (3) before going on to say, “As used here, ‘experiences in global health’ refers to circumstances where physicians from high-income countries travel to low- or middle-income countries or to underserved areas in high-income countries”. The authors seem to have misunderstood the definition put forth by Koplan et al. who don’t emphasize vulnerable populations or underserved settings but instead “emphasizes transnational health issues, determinants, and solutions.” Though important to minimize neo-colonialism in these experiences, the loss of perspective engendered by the rich-poor assumption, as opposed to the broader Koplan definition, fails to recognize the interplay of multiple power imbalances and, for example, the not inconsequential influence that a less-than-benevolent host government may have over the visiting practitioner and communities. Although “global health” has become vernacular for re-branded tropical medicine, medical missions, or low-resource medicine, the discipline is certainly larger than that. Tackling issues such as pharmaceutical evergreening, TRIPS Plus, the opioid epidemic, climate change, viral sovereignty, the political exploitation of natural disasters, resource conflicts, healthcare infrastructure rebuilding in fragile & post-conflict states, rape as a weapon of war, drone warfare, or the global refugee surge do not fit well into an ethics discussion that misunderstands the discipline of global health as the juxta-socioeconomic aspect of medical voluntourism. The Koplan et al. definition has been widely accepted partly because of its effectiveness at differentiating global health from other disciplines such as international health, public health, or tropical medicine. The distinction does matter to practice beyond the academic discourse- an incomplete understanding of what is global health, and what is only a part of it, can ultimately undermine careful efforts to practice equitably and ethically.
While the ethical positions are welcomed, proper representation of the referenced definition and discipline of global health, even without a comprehensive review of the ethical challenges inherent in global health, is important. This is true not only when considering the influence which the ACP Position Paper is likely to carry, but also to better equip practitioners for engaging patients and communities in constrained environments with multiple stakeholders.
Riley G. Jones, MD, MSc, MSc
Global Health Fellow, University of Florida
Disclosures: the author has disclosed no conflicts of interest
1. DeChamp M, Lehmann LS, Jaeel P, Horwitch C; ACP Ethics, Professionalism, and Human Rights Committee. Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper. Ann Intern Med. 168(9):651-657. [PMID:29582076] doi: 10.7326/M17-3361.
2. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993-5. [PMID:19493564] doi:10.1016/S0140-6736(09)60332-9.
3. Medecins Sans Frontieres. MSF History. Accessed at http://www.msf.org/en/msf-history on 23 May 2018.
Matthew DeCamp, MD, PhD, Lisa Soleymani Lehmann, MD, PhD, Pooja Jaeel, MD, and Carrie A. Horwitch, MD, MPH
Johns Hopkins, VA Washington, DC, Harvard, UCSD
June 20, 2018
IN RESPONSE: We are grateful for the comments generated by American College of Physicians (ACP) Position Paper on Ethical Obligations Regarding Short-Term Global Health Clinical Experiences. We applaud Dr. Brinks and colleagues for their work in Myanmar and appreciate its relationship to the ACP’s positions. We agree that organizations have an ethical obligation of transparency to share sufficient information with physicians to aid their decision-making about participation. While we currently lack rigorous, objective metrics, we hope this changes over time. For example, a tool for evaluating a short-term global health program was developed – with input from the local community – to assess costs, health impact, and sustainability (among other parameters).(1) Evaluative efforts should be supported and expanded to include measures relevant to all five ACP positions. Dr. Good and colleagues worry that the ACP positions might dissuade physician participation in global health. Our intent is not to dissuade but to encourage physician participation in programs that meet basic ethical obligations. The flexibility intended by our statement that “there is no ’one-size-fits-all’ approach to ethics” would likely apply to the program maturation Dr. Good et al. describe in Honduras. Still, we emphasize that programs should progress based upon timelines and benchmarks described in the ACP positions. We also agree with Dr. Good et. al that organizations should be transparent regarding their mission and funding. Potential conflicts of interest need to be identified and should not interfere with appropriate medical care by volunteers. Dr. Jones is concerned that we misunderstood Koplan et al.’s definition of global health and thus fail to recognize certain multifaceted ethical issues in global health work. Koplan et al.’s complex definition also states that global health prioritizes “achieving equity in health for all people worldwide” and shares with public and international health a “concentration on poorer, vulnerable, and underserved populations.”(2) The position paper did not propose a comprehensive theory of global health ethics. Circumscribing our definition allowed us to focus on short-term experiences in global health (STEGHS) and medical care delivery within the broader domain of global health. This is an area where ACP and its Ethics, Professionalism, and Human Rights Committee have relevant expertise (with additional input from the International Council and Volunteerism Committee). Nevertheless we agree that recognition of factors such as power imbalances, armed conflict, and governance concerns are important components of predeparture preparation.1. Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res. 2008;8:121. [PMID: 18518997] doi:10.1186/1472-6963-8-1212. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993-5. [PMID: 19493564] doi:10.1016/S0140 -6736(09)60332-9.
DeCamp M, Lehmann LS, Jaeel P, et al, for the ACP Ethics, Professionalism and Human Rights Committee. Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper. Ann Intern Med. 2018;168:651–657. [Epub ahead of print 27 March 2018]. doi: https://doi.org/10.7326/M17-3361
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Published: Ann Intern Med. 2018;168(9):651-657.
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